Page 6 - 2015 NVW Open Enrollment Guide
P. 6
Open
Enrollment
Dental
UnitedHealthcare
PPO Non-PPO
Charges subject to reasonable
and customary allowance
Calendar Year Deductible
Individual $50 $50
Family $150 $150
Calendar Year
Maximum $1,500 $1,500
Coinsurance
Preventive and
Diagnostic 100% no deductible 100% no deductible
Basic Restorative 80% after deductible 80% after deductible
Major Restorative 60% after deductible 50% after deductible
Orthodontic No deductible, 50% to $1,500 No deductible, 50% to $1,500
(dependent children Lifetime Lifetime
to age 19 only)
Covered Under Preventive
Dental Exams, Cleanings, Fluoride Treatment, X-rays, Space
Maintainers, and Sealants
Covered Under Basic
Routine Fillings (amalgams and resins), Simple Extractions,
Stainless Steel Crowns, Endodontics (root canal therapy),
Periodontic Services, General Anesthesia, and Simple
Extractions
Covered Under Major
Major Restorative Services—Crowns, Inlays, Onlays,
Prosthodontic Services, and Oral Surgery
Bi-Weekly Contributions
Employee Only $7 .54
Employee + Spouse $22 .60
Employee + Child(ren) $28 .26
Employee + Family $46 .10
6
Enrollment
Dental
UnitedHealthcare
PPO Non-PPO
Charges subject to reasonable
and customary allowance
Calendar Year Deductible
Individual $50 $50
Family $150 $150
Calendar Year
Maximum $1,500 $1,500
Coinsurance
Preventive and
Diagnostic 100% no deductible 100% no deductible
Basic Restorative 80% after deductible 80% after deductible
Major Restorative 60% after deductible 50% after deductible
Orthodontic No deductible, 50% to $1,500 No deductible, 50% to $1,500
(dependent children Lifetime Lifetime
to age 19 only)
Covered Under Preventive
Dental Exams, Cleanings, Fluoride Treatment, X-rays, Space
Maintainers, and Sealants
Covered Under Basic
Routine Fillings (amalgams and resins), Simple Extractions,
Stainless Steel Crowns, Endodontics (root canal therapy),
Periodontic Services, General Anesthesia, and Simple
Extractions
Covered Under Major
Major Restorative Services—Crowns, Inlays, Onlays,
Prosthodontic Services, and Oral Surgery
Bi-Weekly Contributions
Employee Only $7 .54
Employee + Spouse $22 .60
Employee + Child(ren) $28 .26
Employee + Family $46 .10
6
